Evolution in Senior Housing

In this installment of our design for aging guest writers series, Scott Ball describes the evolution in senior care facility design and in thinking about the senior housing industry.

For the growing collection of planners, architects, urban designers, and health professionals interested in better supporting community-based aging, the senior housing industry often serves as a convenient whipping post. In survey after survey, older adults express a preference for aging-in-place—right in the homes and communities where they currently reside—and a distaste for senior housing options. Senior housing is often negatively associated with a loss of independence, with exile from the community, and with the types of exurban gated developments where old people seem to be rounded up and put out to pasture. An easy way to win an audience’s favor in any lecture on community-based aging is to take a swipe at the senior housing industry—particularly the nursing home segment.

The current call for more community-based aging options, known variously as elder-friendly communities, lifelong communities, lifespan communities, or older adult livable communities, does not need to position itself in opposition to senior housing development models, but rather could be viewed as an application of their core value propositions to a more dispersed and community-integrated context. As the senior-housing industry has evolved, it has created buildings, services, and community-wide features that are uniquely tailored to support an aging population. In many ways, the very existence of these specialized communities is a direct response to deficiencies in the general urban environment. They provide a level of access and support needed by older adults that is unavailable and unsustainable in the wider community. The industry has established simple models (independent living, assisted living, skilled nursing, and so on) for what are, in reality, very complex relationships among real estate, finance, and healthcare industries. They represent complex, integrated approaches to fulfill the needs of older adults. Adaptation to the new market, brought on by the retiring Baby Boomers, could result in a marshaling of these resources and redeployment in creative ways, as infill projects woven into the neighborhoods where older adults so vehemently want to remain.

The negative perception is not a fair assessment of the value of the senior housing type. As Americans enter into a long process of reinventing the opportunities and expectations for the later third of life, it would be beneficial to help shape a productive role for the senior housing industry. The evolution of senior housing over the past half century is a record of institutional care models, moving progressively closer to more neighborhood-like settings. In the mid-twentieth century, early nursing homes grew out of the medical model and looked like hospital buildings both inside and outside. Over the past three decades, alternatives to highly institutional skilled nursing facilities have evolved, each moving progressively closer to more familiar neighborhood forms and styles. Compared to someone’s home of three decades, a senior housing development may seem institutional, but compared to the hospital system from which they have sprung, these developments are as close as the medical model has gotten to providing care in a neighborhood-like environment.

Senior housing development types could be reframed as a critical step in the process of domesticating medical care facilities, bringing clinical services into a scale and form that is more compatible with the neighborhoods where we spend the majority of our lives. Having evolved in response to deficiencies in the general environment, senior housing building types and service offerings may provide valuable tools for making our neighborhoods more elder-friendly.

The promise of senior housing is that it continues to diversify and continues to explore more social, less institutional forms of both facility and program. Senior housing can play a leading role in the effort to better domesticate the medical model, to bring it closer to neighborhood environments, and to integrating medical care into a broad array of healthy everyday routines. The goal of creating community-based continuums of care should include medical and acute care options, and both the communities and the industry would benefit if the distinctions between the places where we conduct healthy daily routines and the places where we receive medical treatment were not so stark.

Seeds of Change
It is no surprise that we ritualistically try to reinvent the last phases of life at each generation; joie de vivre compels older adults to resist the known aspects of decline and search for ways to better champion the positive potentials of the aging process. Grown children’s desires to provide the best for their parents will always focus on avoiding the worst of what they remember their grandparents experiencing. Each successive generation of Americans has tried to do its best in caring for the preceding generation, even as the understanding of what is best changes: initially, healing spa retreats; then sterile environments; then increasingly laboratory-like medical facilities; and now the more familiar neighborhood environments wherein chronic disease can be better managed by improved daily routines. Senior housing has evolved as our ideas of healthcare have evolved, often at the cutting edge of change and fueled by a willingness to try the new with the hope that it will be better than what we know of the old. The ritual of aging is that of continual reinvention, not of tradition, and the senior housing industry is deeply vested in understanding and responding to evolving market desires.

Our attitudes about older adults also change, and this affects preferences for living environments. At the beginning of the twentieth century, older adults were the venerable stewards of institutional wisdom and continuity: the chairs of boards and the chiefs of community organizations. By the second half of the twentieth century, older adults were retirees, relieved of those sorts of institutional burdens and deserving golden years of quiet leisure. Grand civic nursing homes and then golf-oriented retirement communities are obvious expressions of these very different social roles. As we wade into the twenty-first century, the Baby-Boom generation seems intent on forming a new creative class that emphasizes leisure less and focuses more on expression, engagement, and personal growth. This is new, and earlier forms of senior housing were not meant to serve this lifestyle preference. Older adults appear to be imagining roles that are neither dominating and venerable, nor retiring and leisurely. Instead, they are looking to mix it up, to defy specific social categories, and in their individual pursuits, possibly even to meld lifestyles with those of their millennial-generation children. The senior housing industry will need to respond to these desires or be content with serving a decreasing percentage of the already small segment of the older adult population that desires or is unable to avoid age-segregated, senior living developments. Senior housing will need to find ways to mix it up with the wider community in order to serve this much larger market segment.

It is easy to predict that the industry will rise to this challenge. The senior housing type is an evolving cultural form that has much to offer all community-based aging concepts. The senior housing type has already come so far in progressing from a hospital-type building, to a suburban-styled campus development, to current models that are for all purposes self-contained, fully realized versions of traditional neighborhood developments. It is not an impossible leap to take what has been gathered by the industry—the models for integrating real estate investment with the provision of supportive services—and bring these innovations back to the wider community.

Image Problem
According to the 2007 study “Aging in Place in America,” commissioned by Clarity and The EAR Foundation, older adults currently fear moving into a nursing home and losing their independence more than they fear death. When asked what they fear most, older adults’ top four responses were: loss of independence (26%), moving into a nursing home (13%), giving up on driving (11%), and loss of family and friends (11%). Only 3% of seniors said that death is what they fear most. The study also finds that the image problem for nursing homes extends well beyond older adults. Of the adult children of older adults, 82% surveyed fear that their parents will be mistreated in a nursing home and 89% worry that their parents will be sad. As this study indicates, the image problem is actually much worse than a lack of desire for the product; Americans express a significant and specific interest in actively avoiding the offering.

This image problem may in large part be attributed to the form and location of nursing homes and other senior housing facilities. For the past fifty years, senior housing developments have been predominantly approached as specialized suburban forms that are usually organized around recreation facilities, medical supports, or both. The developments have been age-segregated, often regulating the amount of non-senior residents and the duration of stays of non-senior visitors. Most constitute some form of internally oriented compound that contains common spaces for dining, recreation, and some type of medical support or daily assistance. Like the original retirement community in Sun City, Arizona, these developments clearly meet a need and address a market, but do so in a highly specialized, age-homogenous, autonomous urban form, set apart from the surrounding community.

Senior housing has evolved separate from its larger urban context, in part out of necessity. As aging-in-place advocates are fully aware, the nation’s built environment is in many ways not capable of supporting an individual’s needs across a lifespan. In some areas, senior housing is the only appropriately sized alternative to large lot, detached single-family homes. Local zoning boards are often only willing to allow more dense, multifamily arrangements when they are restricted to the elderly and not made available as low-income housing for the general population. As mobility functions decline, senior housing communities may be the only places to find the appropriate accessibility features incorporated throughout the entire environment. Accessible and appropriately structured spaces for social interaction and community engagement are not widely available outside of seniors’ facilities in many areas. Older adults are more susceptible to illness, and senior housing serves as an alternative arrangement to our current hospital-oriented medical system—an alternative to either checking into a hospital for a long stay or remaining at home and foregoing adequate care. With communities and families alike becoming ever more attenuated, senior housing may be the only place an older adult could reliably expect to be able to get help in a crisis event. Having served as a catch-all building type and set of services to fill these gaps, senior housing has a lot to offer a community that wants to do a better job of retaining older adults.

The real differences between housing for the elderly and housing for the rest of the population are relative rather than categorical. Older persons on the whole require more emphasis on certain aspects of living arrangements than the rest of the community, but the differences are of degree rather than of kind. There are benefits to supporting aging in the general built environment. Most of our communities would benefit from increased housing diversity; increased attention to continuous and accessible walking routes; intentional social spaces; convenient access to daily needs, and easier access to both health care and crisis assistance. These are all qualities that provide value for everyone in any community. Senior housing incorporates design features that are necessary for older adults yet still beneficial for the rest of the population, and a community that works well for older adults will provide benefits to all across their life spans. The housing challenges of older adults may today be better approached, for the most part, as a general upgrading of the entire built environment rather than perfection of specialized and age-segregated urban forms. The senior housing industry is beginning to shape a role for itself in this general upgrading process.

Moving To The Neighborhood
Continuing Care Retirement Communities (CCRCs) have become the cutting edge of community-based medical care provision, representing a significant extension of the medical model into the daily life carried out in neighborhood settings. CCRC developers have grown accustomed to operating at the neighborhood scale as well, even if the end product does not always reflect a neighborhood aesthetic or the diversity that would normally be associated with a neighborhood environment. If this evolution toward neighborhood scales and community-like forms continues, senior housing developments could begin to blur distinctions between institutional and home-based care, perhaps even becoming so ubiquitous as to be considered an extension of community-based aging in place rather than an alternative to it. CCRCs have a substantial track record of accomplishment in the fields of environmental health, geriatric care, inter-industry coordination, complex financing, and creative lease, purchase, and fee structures. They have provided spaces and services that make up for deficiencies in the general environmental, social, and economic systems. Both market demand and societal needs would be better served if these resources were better deployed to contribute to and draw on the wider community. Senior housing has an opportunity to become a major civic contributor and would benefit from this engagement in terms of bottom line, public perception, market penetration, and social relevance.

CCRCs have also begun to interact more with the surrounding community through service programming. Providing outreach services to the surrounding community not only maximizes investment in the facility but also develops relationships that might attract future residents. In other cases, outpatient services like rehabilitative therapy are provided out of a facility embedded in a senior housing development that serves the development’s residents and surrounding community alike. The effect of these outpatient and home-based care services is a flow of people into and out of the development that helps break down the strict delineation between life inside the property boundary and life outside. Services delivery and urban form are increasingly blurring the distinction between a senior housing development and its surrounding community.

Conclusion
There are promising signs that senior housing types may be in an awkward stage of development, but that the basic genetics are good and the form embodies a promising potential future. Senior housing has raised the bar for the detailing and programming of supportive environments, and every generation has always sought out the newest and best that can be provided in exchange for the hard work of aging.

The senior housing industry has undergone tumultuous evolution over the past few decades. Starting out as hospital-like facilities, senior living offerings have today diversified into an array of care models ranging from active adult retirement housing, to memory loss units, to rehabilitation facilities, to entire communities that offer a continuum of care. In the next stages of evolution, likely to be driven by the retiring Baby Boomers, the challenge for the senior housing industry may prove to be that of dispersion and integration, of pulling apart and opening up enough to be woven into the broader community fabric. Rather than conceiving of senior housing as a single, isolated development, the future of the industry may belong to providers who invent methods for borrowing on and contributing to a wider, mixed-generation neighborhood. We may be getting close to the point where the senior living industry begins to move away from providing “retirement communities” to providing for retirement in existing communities. Advocates for community-based aging should recognize and help nurture the potential of the senior housing industry.